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City of Cocoa I Employee Benefit Highlights 12020-2021 (e)) <br /> EyeMed Vision Care Plan At-A-Glance <br /> Network Insight <br /> Services In-Network Out-of-Network <br /> Eye Exam No Charge Up to$40 Reimbursement <br /> - - - - Locate a Provider <br /> Frequency of Services To search fora participating provider, <br /> Examination 12 Months contact EyeMed's customer service <br /> or visit www.eyemed.com.When <br /> Lenses 12 Months completing the necessary search <br /> criteria,select Insight network. <br /> Frames 24 Months <br /> Contact Lenses 12 Months <br /> Lenses <br /> 0 <br /> Single No Charge Up to$30 Reimbursement <br /> Bifocal - No Charge Up to$50 Reimbursement Plan References <br /> t Trifocal No Charge Up to$7O Reimbursement *Contact lenses are in lieu of spectacle <br /> lenses. <br /> i Frames <br /> J Allowance Up to$150 Plus 20%Off Balance <br /> over$150 Up to$105 Reimbursement <br /> [[[[ <br /> Contact Lenses* <br /> 0 1 <br /> Non-Elective(Medically Necessary) No Charge Up to$210 Reimbursement <br /> _ Important Notes <br /> Up to$150 Allowance Plus 15%Off <br /> Conventional Up to$150 Reimbursement •Member options,such as LASIK,UV <br /> Balance over$150 coating,progressive lenses,etc.are not <br /> Elective(Fitting,Follow-up&Lenses) I - - - P ro 9 <br /> Up to$150 Allowance Plus Balance covered in full,but maybe available at <br /> iDisposable over$150 Up to$150 Reimbursement a discount. <br /> •Members receive additional fixed <br /> copayments on lens options including <br /> anti-reflective&scratch-resistant <br /> coatings. <br /> •Aftercopay,standard polycarbonate <br /> available at no charge for dependents <br /> less than 19 years old. <br /> 20 <br /> ©2016,Gehring Group,Inc.,All Rights Reserved 12 <br />